|
PERQ TRLUML CORONRY LITHOTRP
|
Facility
|
OP
|
$300.00
|
|
|
Service Code
|
HCPCS 92972
|
| Hospital Charge Code |
76102809
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$39.00 |
| Max. Negotiated Rate |
$288.00 |
| Rate for Payer: Aetna Commercial |
$231.00
|
| Rate for Payer: Anthem Medicaid |
$103.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$234.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cigna Commercial |
$249.00
|
| Rate for Payer: First Health Commercial |
$285.00
|
| Rate for Payer: Humana Commercial |
$255.00
|
| Rate for Payer: Humana KY Medicaid |
$103.17
|
| Rate for Payer: Kentucky WC Medicaid |
$104.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$246.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$221.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$90.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$105.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$264.00
|
| Rate for Payer: Ohio Health Group HMO |
$225.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$60.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$39.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$93.00
|
| Rate for Payer: PHCS Commercial |
$288.00
|
| Rate for Payer: United Healthcare All Payer |
$264.00
|
|
|
PERQ TRLUML CORONRY LITHOTRP
|
Facility
|
IP
|
$11,700.00
|
|
|
Service Code
|
HCPCS 92972
|
| Hospital Charge Code |
48100102
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$1,521.00 |
| Max. Negotiated Rate |
$11,232.00 |
| Rate for Payer: Aetna Commercial |
$9,009.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,126.00
|
| Rate for Payer: Cash Price |
$5,850.00
|
| Rate for Payer: Cigna Commercial |
$9,711.00
|
| Rate for Payer: First Health Commercial |
$11,115.00
|
| Rate for Payer: Humana Commercial |
$9,945.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,594.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,634.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,510.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,296.00
|
| Rate for Payer: Ohio Health Group HMO |
$8,775.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,340.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,521.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,627.00
|
| Rate for Payer: PHCS Commercial |
$11,232.00
|
| Rate for Payer: United Healthcare All Payer |
$10,296.00
|
|
|
PERQ TRLUML CORONRY LITHOTRP
|
Professional
|
Both
|
$11,700.00
|
|
|
Service Code
|
HCPCS 92972
|
| Hospital Charge Code |
48100102
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$122.47 |
| Max. Negotiated Rate |
$11,700.00 |
| Rate for Payer: Anthem Medicaid |
$122.47
|
| Rate for Payer: Buckeye Medicare Advantage |
$11,700.00
|
| Rate for Payer: Cash Price |
$5,850.00
|
| Rate for Payer: Cash Price |
$5,850.00
|
| Rate for Payer: Humana Medicaid |
$122.47
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$124.92
|
| Rate for Payer: Molina Healthcare Passport |
$122.47
|
| Rate for Payer: Multiplan PHCS |
$7,020.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$8,190.00
|
| Rate for Payer: UHCCP Medicaid |
$4,095.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$123.69
|
|
|
PERQ TRLUML CORONRY LITHOTRP
|
Professional
|
Both
|
$300.00
|
|
|
Service Code
|
HCPCS 92972
|
| Hospital Charge Code |
76102809
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$105.00 |
| Max. Negotiated Rate |
$300.00 |
| Rate for Payer: Anthem Medicaid |
$122.47
|
| Rate for Payer: Buckeye Medicare Advantage |
$300.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Humana Medicaid |
$122.47
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$124.92
|
| Rate for Payer: Molina Healthcare Passport |
$122.47
|
| Rate for Payer: Multiplan PHCS |
$180.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$210.00
|
| Rate for Payer: UHCCP Medicaid |
$105.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$123.69
|
|
|
PERSANTINE (DIPYRIDA 25MG/1TAB
|
Facility
|
OP
|
$9.18
|
|
|
Service Code
|
NDC 64980013301
|
| Hospital Charge Code |
25001178
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.19 |
| Max. Negotiated Rate |
$8.81 |
| Rate for Payer: Aetna Commercial |
$7.07
|
| Rate for Payer: Anthem Medicaid |
$3.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.16
|
| Rate for Payer: Cash Price |
$4.59
|
| Rate for Payer: Cigna Commercial |
$7.62
|
| Rate for Payer: First Health Commercial |
$8.72
|
| Rate for Payer: Humana Commercial |
$7.80
|
| Rate for Payer: Humana KY Medicaid |
$3.16
|
| Rate for Payer: Kentucky WC Medicaid |
$3.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.08
|
| Rate for Payer: Ohio Health Group HMO |
$6.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.85
|
| Rate for Payer: PHCS Commercial |
$8.81
|
| Rate for Payer: United Healthcare All Payer |
$8.08
|
|
|
PERSANTINE (DIPYRIDA 25MG/1TAB
|
Facility
|
IP
|
$9.18
|
|
|
Service Code
|
NDC 64980013301
|
| Hospital Charge Code |
25001178
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.19 |
| Max. Negotiated Rate |
$8.81 |
| Rate for Payer: Aetna Commercial |
$7.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.16
|
| Rate for Payer: Cash Price |
$4.59
|
| Rate for Payer: Cigna Commercial |
$7.62
|
| Rate for Payer: First Health Commercial |
$8.72
|
| Rate for Payer: Humana Commercial |
$7.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.08
|
| Rate for Payer: Ohio Health Group HMO |
$6.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.85
|
| Rate for Payer: PHCS Commercial |
$8.81
|
| Rate for Payer: United Healthcare All Payer |
$8.08
|
|
|
PERSERIS 0.5mg (120mg Kit)
|
Facility
|
IP
|
$15,798.68
|
|
|
Service Code
|
HCPCS J2798
|
| Hospital Charge Code |
25004327
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,053.83 |
| Max. Negotiated Rate |
$15,166.73 |
| Rate for Payer: Aetna Commercial |
$12,164.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,322.97
|
| Rate for Payer: Cash Price |
$7,899.34
|
| Rate for Payer: Cigna Commercial |
$13,112.90
|
| Rate for Payer: First Health Commercial |
$15,008.75
|
| Rate for Payer: Humana Commercial |
$13,428.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,954.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,659.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,739.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,902.84
|
| Rate for Payer: Ohio Health Group HMO |
$11,849.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,159.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,053.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,897.59
|
| Rate for Payer: PHCS Commercial |
$15,166.73
|
| Rate for Payer: United Healthcare All Payer |
$13,902.84
|
|
|
PERSERIS 0.5mg (120mg Kit)
|
Facility
|
OP
|
$15,798.68
|
|
|
Service Code
|
HCPCS J2798
|
| Hospital Charge Code |
25004327
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.55 |
| Max. Negotiated Rate |
$15,166.73 |
| Rate for Payer: Aetna Commercial |
$12,164.98
|
| Rate for Payer: Anthem Medicaid |
$5,433.17
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$10.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,322.97
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$14.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$14.24
|
| Rate for Payer: Cash Price |
$7,899.34
|
| Rate for Payer: Cash Price |
$7,899.34
|
| Rate for Payer: Cigna Commercial |
$13,112.90
|
| Rate for Payer: First Health Commercial |
$15,008.75
|
| Rate for Payer: Humana Commercial |
$13,428.88
|
| Rate for Payer: Humana KY Medicaid |
$5,433.17
|
| Rate for Payer: Humana Medicare Advantage |
$10.55
|
| Rate for Payer: Kentucky WC Medicaid |
$5,488.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,954.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,659.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,542.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,902.84
|
| Rate for Payer: Ohio Health Group HMO |
$11,849.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,159.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,053.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,897.59
|
| Rate for Payer: PHCS Commercial |
$15,166.73
|
| Rate for Payer: United Healthcare All Payer |
$13,902.84
|
|
|
PERSERIS 0.5mg (90mg Kit)
|
Facility
|
IP
|
$11,848.90
|
|
|
Service Code
|
HCPCS J2798
|
| Hospital Charge Code |
25004326
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,540.36 |
| Max. Negotiated Rate |
$11,374.94 |
| Rate for Payer: Aetna Commercial |
$9,123.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,242.14
|
| Rate for Payer: Cash Price |
$5,924.45
|
| Rate for Payer: Cigna Commercial |
$9,834.59
|
| Rate for Payer: First Health Commercial |
$11,256.46
|
| Rate for Payer: Humana Commercial |
$10,071.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,716.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,744.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,554.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,427.03
|
| Rate for Payer: Ohio Health Group HMO |
$8,886.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,369.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,540.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,673.16
|
| Rate for Payer: PHCS Commercial |
$11,374.94
|
| Rate for Payer: United Healthcare All Payer |
$10,427.03
|
|
|
PERSERIS 0.5mg (90mg Kit)
|
Facility
|
OP
|
$11,848.90
|
|
|
Service Code
|
HCPCS J2798
|
| Hospital Charge Code |
25004326
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.55 |
| Max. Negotiated Rate |
$11,374.94 |
| Rate for Payer: Aetna Commercial |
$9,123.65
|
| Rate for Payer: Anthem Medicaid |
$4,074.84
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$10.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,242.14
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$14.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$14.24
|
| Rate for Payer: Cash Price |
$5,924.45
|
| Rate for Payer: Cash Price |
$5,924.45
|
| Rate for Payer: Cigna Commercial |
$9,834.59
|
| Rate for Payer: First Health Commercial |
$11,256.46
|
| Rate for Payer: Humana Commercial |
$10,071.56
|
| Rate for Payer: Humana KY Medicaid |
$4,074.84
|
| Rate for Payer: Humana Medicare Advantage |
$10.55
|
| Rate for Payer: Kentucky WC Medicaid |
$4,116.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,716.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,744.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,156.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,427.03
|
| Rate for Payer: Ohio Health Group HMO |
$8,886.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,369.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,540.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,673.16
|
| Rate for Payer: PHCS Commercial |
$11,374.94
|
| Rate for Payer: United Healthcare All Payer |
$10,427.03
|
|
|
PERTUSSIS DETECT AGENT EACH
|
Facility
|
OP
|
$277.00
|
|
|
Service Code
|
HCPCS 87798
|
| Hospital Charge Code |
30001400
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$35.09 |
| Max. Negotiated Rate |
$265.92 |
| Rate for Payer: Aetna Commercial |
$213.29
|
| Rate for Payer: Anthem Medicaid |
$35.09
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$35.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$222.43
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$49.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$35.09
|
| Rate for Payer: Cash Price |
$138.50
|
| Rate for Payer: Cash Price |
$138.50
|
| Rate for Payer: Cigna Commercial |
$229.91
|
| Rate for Payer: First Health Commercial |
$263.15
|
| Rate for Payer: Humana Commercial |
$235.45
|
| Rate for Payer: Humana KY Medicaid |
$35.09
|
| Rate for Payer: Humana Medicare Advantage |
$35.09
|
| Rate for Payer: Kentucky WC Medicaid |
$35.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$227.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$204.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.11
|
| Rate for Payer: Molina Healthcare Medicaid |
$35.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$243.76
|
| Rate for Payer: Ohio Health Group HMO |
$207.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$55.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$36.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$85.87
|
| Rate for Payer: PHCS Commercial |
$265.92
|
| Rate for Payer: United Healthcare All Payer |
$243.76
|
|
|
PERTUSSIS DETECT AGENT EACH
|
Facility
|
IP
|
$277.00
|
|
|
Service Code
|
HCPCS 87798
|
| Hospital Charge Code |
30001400
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$36.01 |
| Max. Negotiated Rate |
$265.92 |
| Rate for Payer: Aetna Commercial |
$213.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$222.43
|
| Rate for Payer: Cash Price |
$138.50
|
| Rate for Payer: Cigna Commercial |
$229.91
|
| Rate for Payer: First Health Commercial |
$263.15
|
| Rate for Payer: Humana Commercial |
$235.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$227.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$204.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$83.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$243.76
|
| Rate for Payer: Ohio Health Group HMO |
$207.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$55.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$36.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$85.87
|
| Rate for Payer: PHCS Commercial |
$265.92
|
| Rate for Payer: United Healthcare All Payer |
$243.76
|
|
|
PERTUZUMAB 1 MG (420MG/14ML)
|
Facility
|
OP
|
$35,570.95
|
|
|
Service Code
|
HCPCS J9306
|
| Hospital Charge Code |
25002673
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.43 |
| Max. Negotiated Rate |
$34,148.11 |
| Rate for Payer: Aetna Commercial |
$27,389.63
|
| Rate for Payer: Anthem Medicaid |
$12,232.85
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$15.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,745.34
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$21.60
|
| Rate for Payer: CareSource Just4Me Medicare |
$20.83
|
| Rate for Payer: Cash Price |
$17,785.47
|
| Rate for Payer: Cash Price |
$17,785.47
|
| Rate for Payer: Cigna Commercial |
$29,523.89
|
| Rate for Payer: First Health Commercial |
$33,792.40
|
| Rate for Payer: Humana Commercial |
$30,235.31
|
| Rate for Payer: Humana KY Medicaid |
$12,232.85
|
| Rate for Payer: Humana Medicare Advantage |
$15.43
|
| Rate for Payer: Kentucky WC Medicaid |
$12,357.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29,168.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26,251.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.51
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,478.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$31,302.44
|
| Rate for Payer: Ohio Health Group HMO |
$26,678.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,114.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,624.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,026.99
|
| Rate for Payer: PHCS Commercial |
$34,148.11
|
| Rate for Payer: United Healthcare All Payer |
$31,302.44
|
|
|
PERTUZUMAB 1 MG (420MG/14ML)
|
Facility
|
IP
|
$35,570.95
|
|
|
Service Code
|
HCPCS J9306
|
| Hospital Charge Code |
25002673
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,624.22 |
| Max. Negotiated Rate |
$34,148.11 |
| Rate for Payer: Aetna Commercial |
$27,389.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27,745.34
|
| Rate for Payer: Cash Price |
$17,785.47
|
| Rate for Payer: Cigna Commercial |
$29,523.89
|
| Rate for Payer: First Health Commercial |
$33,792.40
|
| Rate for Payer: Humana Commercial |
$30,235.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29,168.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26,251.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,671.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$31,302.44
|
| Rate for Payer: Ohio Health Group HMO |
$26,678.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,114.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,624.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,026.99
|
| Rate for Payer: PHCS Commercial |
$34,148.11
|
| Rate for Payer: United Healthcare All Payer |
$31,302.44
|
|
|
PET AQMBF PET REST & RX STRESS
|
Professional
|
Both
|
$4,512.00
|
|
|
Service Code
|
HCPCS 78434
|
| Hospital Charge Code |
40400005
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$35.27 |
| Max. Negotiated Rate |
$4,512.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$4,512.00
|
| Rate for Payer: Cash Price |
$2,256.00
|
| Rate for Payer: Cash Price |
$2,256.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$35.27
|
| Rate for Payer: Multiplan PHCS |
$2,707.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,158.40
|
| Rate for Payer: UHCCP Medicaid |
$1,579.20
|
|
|
PET AQMBF PET REST & RX STRESS
|
Facility
|
OP
|
$4,512.00
|
|
|
Service Code
|
HCPCS 78434
|
| Hospital Charge Code |
40400005
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$586.56 |
| Max. Negotiated Rate |
$4,331.52 |
| Rate for Payer: Aetna Commercial |
$3,474.24
|
| Rate for Payer: Anthem Medicaid |
$1,551.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,519.36
|
| Rate for Payer: Cash Price |
$2,256.00
|
| Rate for Payer: Cigna Commercial |
$3,744.96
|
| Rate for Payer: First Health Commercial |
$4,286.40
|
| Rate for Payer: Humana Commercial |
$3,835.20
|
| Rate for Payer: Humana KY Medicaid |
$1,551.68
|
| Rate for Payer: Kentucky WC Medicaid |
$1,567.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,699.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,329.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,353.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,582.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,970.56
|
| Rate for Payer: Ohio Health Group HMO |
$3,384.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$902.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$586.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,398.72
|
| Rate for Payer: PHCS Commercial |
$4,331.52
|
| Rate for Payer: United Healthcare All Payer |
$3,970.56
|
|
|
PET AQMBF PET REST & RX STRESS
|
Facility
|
IP
|
$4,512.00
|
|
|
Service Code
|
HCPCS 78434
|
| Hospital Charge Code |
40400005
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$586.56 |
| Max. Negotiated Rate |
$4,331.52 |
| Rate for Payer: Aetna Commercial |
$3,474.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,519.36
|
| Rate for Payer: Cash Price |
$2,256.00
|
| Rate for Payer: Cigna Commercial |
$3,744.96
|
| Rate for Payer: First Health Commercial |
$4,286.40
|
| Rate for Payer: Humana Commercial |
$3,835.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,699.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,329.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,353.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,970.56
|
| Rate for Payer: Ohio Health Group HMO |
$3,384.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$902.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$586.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,398.72
|
| Rate for Payer: PHCS Commercial |
$4,331.52
|
| Rate for Payer: United Healthcare All Payer |
$3,970.56
|
|
|
PET CT FULLBODY
|
Professional
|
Both
|
$7,156.00
|
|
|
Service Code
|
HCPCS 78816
|
| Hospital Charge Code |
40400009
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$143.09 |
| Max. Negotiated Rate |
$7,156.00 |
| Rate for Payer: Aetna Commercial |
$2,081.06
|
| Rate for Payer: Anthem Medicaid |
$1,046.34
|
| Rate for Payer: Buckeye Medicare Advantage |
$7,156.00
|
| Rate for Payer: Cash Price |
$3,578.00
|
| Rate for Payer: Cash Price |
$3,578.00
|
| Rate for Payer: Cigna Commercial |
$754.72
|
| Rate for Payer: Healthspan PPO |
$1,126.34
|
| Rate for Payer: Humana Medicaid |
$1,046.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$143.09
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,067.27
|
| Rate for Payer: Molina Healthcare Passport |
$1,046.34
|
| Rate for Payer: Multiplan PHCS |
$4,293.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$5,009.20
|
| Rate for Payer: UHCCP Medicaid |
$2,504.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,056.80
|
|
|
PET CT FULLBODY
|
Facility
|
OP
|
$7,156.00
|
|
|
Service Code
|
HCPCS 78816
|
| Hospital Charge Code |
40400009
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$930.28 |
| Max. Negotiated Rate |
$6,869.76 |
| Rate for Payer: Aetna Commercial |
$5,510.12
|
| Rate for Payer: Anthem Medicaid |
$2,460.95
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,352.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,581.68
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,894.02
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,826.37
|
| Rate for Payer: Cash Price |
$3,578.00
|
| Rate for Payer: Cash Price |
$3,578.00
|
| Rate for Payer: Cigna Commercial |
$5,939.48
|
| Rate for Payer: First Health Commercial |
$6,798.20
|
| Rate for Payer: Humana Commercial |
$6,082.60
|
| Rate for Payer: Humana KY Medicaid |
$2,460.95
|
| Rate for Payer: Humana Medicare Advantage |
$1,352.87
|
| Rate for Payer: Kentucky WC Medicaid |
$2,485.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,867.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,281.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,623.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,510.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,297.28
|
| Rate for Payer: Ohio Health Group HMO |
$5,367.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,431.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$930.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,218.36
|
| Rate for Payer: PHCS Commercial |
$6,869.76
|
| Rate for Payer: United Healthcare All Payer |
$6,297.28
|
|
|
PET CT FULLBODY
|
Professional
|
Both
|
$225.00
|
|
|
Service Code
|
HCPCS 78816
|
| Hospital Charge Code |
404P0009
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$78.75 |
| Max. Negotiated Rate |
$2,081.06 |
| Rate for Payer: Aetna Commercial |
$2,081.06
|
| Rate for Payer: Anthem Medicaid |
$1,046.34
|
| Rate for Payer: Buckeye Medicare Advantage |
$225.00
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cigna Commercial |
$754.72
|
| Rate for Payer: Healthspan PPO |
$1,126.34
|
| Rate for Payer: Humana Medicaid |
$1,046.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$143.09
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,067.27
|
| Rate for Payer: Molina Healthcare Passport |
$1,046.34
|
| Rate for Payer: Multiplan PHCS |
$135.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$157.50
|
| Rate for Payer: UHCCP Medicaid |
$78.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,056.80
|
|
|
PET CT FULLBODY
|
Facility
|
IP
|
$7,156.00
|
|
|
Service Code
|
HCPCS 78816
|
| Hospital Charge Code |
40400009
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$930.28 |
| Max. Negotiated Rate |
$6,869.76 |
| Rate for Payer: Aetna Commercial |
$5,510.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,581.68
|
| Rate for Payer: Cash Price |
$3,578.00
|
| Rate for Payer: Cigna Commercial |
$5,939.48
|
| Rate for Payer: First Health Commercial |
$6,798.20
|
| Rate for Payer: Humana Commercial |
$6,082.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,867.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,281.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,146.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,297.28
|
| Rate for Payer: Ohio Health Group HMO |
$5,367.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,431.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$930.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,218.36
|
| Rate for Payer: PHCS Commercial |
$6,869.76
|
| Rate for Payer: United Healthcare All Payer |
$6,297.28
|
|
|
PET CT FULLBODY(T
|
Facility
|
OP
|
$6,931.00
|
|
|
Service Code
|
HCPCS 78816
|
| Hospital Charge Code |
404T0009
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$901.03 |
| Max. Negotiated Rate |
$6,653.76 |
| Rate for Payer: Aetna Commercial |
$5,336.87
|
| Rate for Payer: Anthem Medicaid |
$2,383.57
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,352.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,406.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,894.02
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,826.37
|
| Rate for Payer: Cash Price |
$3,465.50
|
| Rate for Payer: Cash Price |
$3,465.50
|
| Rate for Payer: Cigna Commercial |
$5,752.73
|
| Rate for Payer: First Health Commercial |
$6,584.45
|
| Rate for Payer: Humana Commercial |
$5,891.35
|
| Rate for Payer: Humana KY Medicaid |
$2,383.57
|
| Rate for Payer: Humana Medicare Advantage |
$1,352.87
|
| Rate for Payer: Kentucky WC Medicaid |
$2,407.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,683.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,115.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,623.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,431.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,099.28
|
| Rate for Payer: Ohio Health Group HMO |
$5,198.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,386.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$901.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,148.61
|
| Rate for Payer: PHCS Commercial |
$6,653.76
|
| Rate for Payer: United Healthcare All Payer |
$6,099.28
|
|
|
PET CT FULLBODY(T
|
Facility
|
IP
|
$6,931.00
|
|
|
Service Code
|
HCPCS 78816
|
| Hospital Charge Code |
404T0009
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$901.03 |
| Max. Negotiated Rate |
$6,653.76 |
| Rate for Payer: Aetna Commercial |
$5,336.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,406.18
|
| Rate for Payer: Cash Price |
$3,465.50
|
| Rate for Payer: Cigna Commercial |
$5,752.73
|
| Rate for Payer: First Health Commercial |
$6,584.45
|
| Rate for Payer: Humana Commercial |
$5,891.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,683.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,115.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,079.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,099.28
|
| Rate for Payer: Ohio Health Group HMO |
$5,198.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,386.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$901.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,148.61
|
| Rate for Payer: PHCS Commercial |
$6,653.76
|
| Rate for Payer: United Healthcare All Payer |
$6,099.28
|
|
|
PET CT SKULL TO THIGH
|
Professional
|
Both
|
$7,156.00
|
|
|
Service Code
|
HCPCS 78815
|
| Hospital Charge Code |
40400008
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$140.77 |
| Max. Negotiated Rate |
$7,156.00 |
| Rate for Payer: Aetna Commercial |
$2,081.06
|
| Rate for Payer: Anthem Medicaid |
$1,044.56
|
| Rate for Payer: Buckeye Medicare Advantage |
$7,156.00
|
| Rate for Payer: Cash Price |
$3,578.00
|
| Rate for Payer: Cash Price |
$3,578.00
|
| Rate for Payer: Cigna Commercial |
$736.80
|
| Rate for Payer: Healthspan PPO |
$1,123.01
|
| Rate for Payer: Humana Medicaid |
$1,044.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$140.77
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,065.45
|
| Rate for Payer: Molina Healthcare Passport |
$1,044.56
|
| Rate for Payer: Multiplan PHCS |
$4,293.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$5,009.20
|
| Rate for Payer: UHCCP Medicaid |
$2,504.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,055.01
|
|
|
PET CT SKULL TO THIGH
|
Facility
|
IP
|
$7,156.00
|
|
|
Service Code
|
HCPCS 78815
|
| Hospital Charge Code |
40400008
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$930.28 |
| Max. Negotiated Rate |
$6,869.76 |
| Rate for Payer: Aetna Commercial |
$5,510.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,581.68
|
| Rate for Payer: Cash Price |
$3,578.00
|
| Rate for Payer: Cigna Commercial |
$5,939.48
|
| Rate for Payer: First Health Commercial |
$6,798.20
|
| Rate for Payer: Humana Commercial |
$6,082.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,867.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,281.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,146.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,297.28
|
| Rate for Payer: Ohio Health Group HMO |
$5,367.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,431.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$930.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,218.36
|
| Rate for Payer: PHCS Commercial |
$6,869.76
|
| Rate for Payer: United Healthcare All Payer |
$6,297.28
|
|
